Pregnancy in women with congenital heart disease: a focus on management and preventing the risk of complications

ABSTRACT

Introduction

Congenital heart disease (CHD) is the most common cardiac disorder in pregnancy in the western world (around 80%). Due to improvements in surgical interventions more women with CHD are surviving to adulthood and choosing to become pregnant.

Areas covered

Preconception counseling, antenatal management of CHDs and strategies to prevent maternal and fetal complications.

Preconception counseling should start early, before the transition to adult care and be offered to both men and women. It should include the choice of contraception, lifestyle modifications, pre-pregnancy optimization of cardiac state, the chance of the child inheriting a similar cardiac lesion, the risks to the mother, and long-term prognosis. Pregnancy induces marked physiological changes in the cardiovascular system that may precipitate cardiac complications. Risk stratification is based on the underlying cardiac disease and data from studies including CARPREG, ZAHARA, and ROPAC.

Expert opinion

Women with left to right shunts, regurgitant lesions, and most corrected CHDs are at lower risk and can be managed in secondary care. Complex CHD, including systemic right ventricle need expert counseling in a tertiary center. Those with severe stenotic lesions, pulmonary artery hypertension, and Eisenmenger’s syndrome should avoid pregnancy, be given effective contraception and managed in a tertiary center if pregnancy does happen.

KEYWORDS:

• Congenital heart disease
• reproductive health
• assisted reproductive technology
• pregnancy
• contraception

Article highlights

• Preconception counseling for both men and women with CHD during transition from pediatric to adult cardiac service.

• Effective contraception to allow optimization of cardiac state and to change teratogenic drugs.

• Pregnancy is contraindicated in women classified as mWHO Class IV and if it occurs, women should be offered the option of termination as soon as possible.

• Women in mWHO Class III or IV should be managed by a multidisciplinary team in a tertiary center.

• Risk of aortic dissection is elevated in pregnancy. Women with Heritable Thoracic Aortic Disease (HTAD), bicuspid aortic valve (BAV), or Turner syndrome should have serial echocardiograms to monitor aortic root dimension during pregnancy and in the postpartum period.

• Vaginal delivery is preferred in most cases.

• Venous thromboembolism (VTE) prophylaxis post-delivery is adjusted according to obstetric guidelines as the postpartum period is the time for highest risk of VTE.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.